Micronutrient supplements in pregnancy: an urgent priority
Authors: Anura V Kurpad, Harshpal Singh Sachdev
Journal: The Lancet Global Health (2022)

In their Correspondence (September, 2022),1Gomes F Black RE Smith E Shankar AH Christian P Micronutrients supplements in pregnancy: an urgent priority.Lancet Glob Health. 2022; 10e1239Summary Full Text Full Text PDF PubMed Scopus (0) Google Scholar Filomena Gomes and colleagues critique our Comment,2Kurpad AV Sachdev HS Precision in prescription: multiple micronutrient supplements in pregnancy.Lancet Glob Health. 2022; 10: e780-e781Summary Full Text Full Text PDF PubMed Scopus (3) Google Scholar which called for more precision in the use of antenatal multiple micronutrient supplementation (MMS). They say our request for precision is "aspirational" but dismiss it as "yet to be achieved in any nation". They also suggest that the relevant benefit of MMS on birthweight and gestational age3Caniglia EC Zash R Swanson SA et al.Iron, folic acid, and multiple micronutrient supplementation strategies during pregnancy and adverse birth outcomes in Botswana.Lancet Glob Health. 2022; 10: e850-e861Summary Full Text Full Text PDF PubMed Scopus (5) Google Scholar lies at the lower tail of the outcome distribution. The fact that benefits are only observed in the population existing at the lower tail of the outcome distribution is the best reason to be precise about supplementation. We believe that, until proved otherwise, we should give supplements only to individuals who need them. However, even this purported and targeted benefit is speculative without any convincing data to show that the relevant benefits were indeed restricted to the lower tail of the distribution.3Caniglia EC Zash R Swanson SA et al.Iron, folic acid, and multiple micronutrient supplementation strategies during pregnancy and adverse birth outcomes in Botswana.Lancet Glob Health. 2022; 10: e850-e861Summary Full Text Full Text PDF PubMed Scopus (5) Google Scholar Gomes and colleagues1Gomes F Black RE Smith E Shankar AH Christian P Micronutrients supplements in pregnancy: an urgent priority.Lancet Glob Health. 2022; 10e1239Summary Full Text Full Text PDF PubMed Scopus (0) Google Scholar further suggest that our concern about excessive intake of micronutrients is misplaced, quoting that the intake of MMS would not exceed the tolerable upper limit of intake. We did not refer to the upper limit,2Kurpad AV Sachdev HS Precision in prescription: multiple micronutrient supplements in pregnancy.Lancet Glob Health. 2022; 10: e780-e781Summary Full Text Full Text PDF PubMed Scopus (3) Google Scholar speaking instead to the need to take care not to create nutrient imbalances at intakes below the upper limit, with potential subclinical metabolic harm, supported by published clinical evidence (eg, the association of maternal red blood cell folate with gestational diabetes4Li N Jiang J Guo L Effects of maternal folate and vitamin B12 on gestational diabetes mellitus: a dose-response meta-analysis of observational studies.Eur J Clin Nutr. 2022; (published online Feb 1.)https://doi.org/10.1038/s41430-022-01076-8Crossref Scopus (8) Google Scholar). Gomes and colleagues1Gomes F Black RE Smith E Shankar AH Christian P Micronutrients supplements in pregnancy: an urgent priority.Lancet Glob Health. 2022; 10e1239Summary Full Text Full Text PDF PubMed Scopus (0) Google Scholar cite potential long-term benefits of MMS as a counter-argument, but that argument is unconvincing when there is also evidence for potential harm. Finally, Gomes and colleagues1Gomes F Black RE Smith E Shankar AH Christian P Micronutrients supplements in pregnancy: an urgent priority.Lancet Glob Health. 2022; 10e1239Summary Full Text Full Text PDF PubMed Scopus (0) Google Scholar suggest that a diverse diet is central, yet dismiss an adequate diet as not being accessible to most pregnant women in LMICs. However, an effort to improve the diversity of food intake through farming systems showed positive results on dietary nutrient adequacy in two rural districts in India.5Pradhan A Raju S Nithya DJ et al.Farming System for Nutrition—a pathway to dietary diversity: evidence from India.PLoS One. 2021; 16e0248698Crossref Scopus (7) Google Scholar A particularly important research design would be a head-to-head comparison of improved dietary diversity with pharmacological supplementation. Dismissing the need for diet diversity by blaming the supposed impracticality of implementation is the heart of the problem, which will, ironically, persist as long as so-called magic bullets continue to be pursued. There is good reason for nothing to be achieved when no attempt is made. We urge utmost care and precision when prescribing one-size-fits-all nutritional supplements, the dose of which could be excessive for people with smaller-than-average body sizes. We live in an area of the world where these supplements are intended, and ask for research, thoughtful restraint, and precision. We encourage researchers to take on the challenge of identifying and targeting individuals in need of nutrient supplementation, rather than showering pills on the entire population. We also reject the statement that such universal policies will be accompanied by simultaneous dietary diversity policies. The provision of safer and sustainable dietary diversity must be upfront and centre stage in policy. HSS was a member of the WHO Guideline Group that drafted recommendations on multiple micronutrient supplements during pregnancy. HSS and AVK are recipients of the Wellcome Trust/Department of Biotechnology India Alliance Clinical/Public Health Research Centre grant (IA/CRC/19/1/610006). AVK is also supported by the India Alliance through their Margdarshi Fellowship. Precision in prescription: multiple micronutrient supplements in pregnancyThe programmatic possibility of introducing multiple micronutrient supplements (MMS), which include iron and folic acid, for routine antenatal care in low-income and middle-income countries (LMIC) has been enthusiastically welcomed by many, but it is equally opposed by others. This is reflected in the language of the WHO recommendation,1 which states that more rigorous research is required, specifically, using early ultrasound to date pregnancies accurately and to rigorously evaluate outcomes and the follow-up of infants into childhood. Full-Text PDF Open Access